Lucky Barriers <ul><li>Update of slide show sent out as an issue of “The Firebird Forum”  </li></ul><ul><li>Show it to you...
Lucky Barrier Anything that does or did protect something worth protecting, but is so fragile as to be &quot;lucky.&quot; ...
A Picture is Worth 1000 Words. Without the Lucky Barriers  near misses would be Real McCoys © 2010, William R. Corcoran, N...
Fragility of Effective and Unchallenged Barriers Positive Control  Of Tools Pre-job Brief Lanyards For Tools Restraining L...
© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu The Lucky Barrier comes in here!!
© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Eight Questions For Insight Quality & Saf...
 
Lucky Barrier Case <ul><li>Submarine erroneously loads oxygen into potable water (PW) connection. PW vents inboard. (PW an...
Lucky Barrier Case <ul><li>Operator attending to Motor Control Center. </li></ul><ul><li>Operator needs to have Control Ro...
Lucky Barrier Case © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Lucky Barrier Case <ul><li>Wrong valve identified for work. </li></ul><ul><li>Grinder cut into pressurized hydrogen line. ...
Lucky Barrier  Case <ul><li>Hoist Falls from Monorail. </li></ul><ul><li>Normally occupied area. </li></ul><ul><li>Not occ...
Lucky Barrier Case <ul><li>Pressurized Water Reactor. </li></ul><ul><li>PORV sticks open. </li></ul><ul><li>Pressurizer le...
Lucky Barrier Case <ul><li>Electrical Equipment Room (EER) Flooding. </li></ul><ul><li>Operators do not know it. </li></ul...
Lucky Barrier Case <ul><li>Scaffold built in line-of-fire of MSIV operator stroke. </li></ul><ul><li>Routine test impacts ...
Lucky Barrier Case <ul><li>U. S. Airways Flight 1549 engines strike Canada Geese </li></ul><ul><li>Has certain altitude an...
Other Lucky Barrier Cases <ul><li>Davis-Besse 2002 </li></ul><ul><ul><li>LB=Leakage at Oconee </li></ul></ul><ul><li>NWA 2...
Send your favorite Lucky Barrier case to [email_address]
Lucky Barrier Facts <ul><li>Lucky Barriers tend to be inconsistent and unreliable. </li></ul><ul><li>Without the Lucky Bar...
Lucky Barrier Lessons to be Learned <ul><li>Be sure you understand the factors that resulted in the nature, the magnitude,...
Lucky Barrier Lessons to be Learned <ul><li>The Lucky Barriers will be among the preventive factors and mitigating factors...
Lucky Barrier(LB) Action Items <ul><li>Discuss the LBs in your Executive Summary. </li></ul><ul><li>Put the LBs in your Co...
Oh, by the way. <ul><li>If you can take a picture of your Lucky Barrier, do so. </li></ul><ul><li>Use it in your RCAR. </l...
Send your favorite Lucky Barrier action items and pictures to [email_address]
Lucky Barriers  Bottom Line <ul><li>Luck is not a robust barrier. </li></ul><ul><li>Luck is an information-rich barrier. <...
Subscribe to “The Firebird Forum” by sending an e-mail to: [email_address]
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Tff V11 N01 Lucky Barriers Updated 2010 03 01

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Entertaining and educational slideshow on Lucky Barriers.

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  • The venue is a four unit generating station in which all four units are in one huge building. Workers erroneously ground into a hydrogen line that was unintentionally pressurized. This could have resulted in filling the building with a hydrogen-air mixture, leading to a high-energy explosion or deflagration. The situation was saved when the grinder sparks turned the hydrogen jet into a &amp;quot;Bunsen burner.&amp;quot; Oh, and to top things off, the Bunsen burner line-of-fire did not include any flammable materials.
  • Tff V11 N01 Lucky Barriers Updated 2010 03 01

    1. 1. Lucky Barriers <ul><li>Update of slide show sent out as an issue of “The Firebird Forum” </li></ul><ul><li>Show it to your rooticians and their stakeholders, e.g., management, CARB. </li></ul>© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
    2. 2. Lucky Barrier Anything that does or did protect something worth protecting, but is so fragile as to be &quot;lucky.&quot; © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
    3. 3. A Picture is Worth 1000 Words. Without the Lucky Barriers near misses would be Real McCoys © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
    4. 4. Fragility of Effective and Unchallenged Barriers Positive Control Of Tools Pre-job Brief Lanyards For Tools Restraining Lip on Scaffold Deck Situational Awareness Preventing Work Under Scaffold (Luck) Hard Hat First Aid Assistance Medical Assistance Ineffective: See actual hazards. Ineffective: Worker set hammer down. Ineffective: Hammer not tethered. Ineffective: Gap in restraining lip. Ineffective: Worker A Kicks Hammer Off Deck.. Ineffective: Worker B Under Scaffold Effective Barrier: Hammer Misses Worker B Not Challenged Not Challenged Not Challenged ?? © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Ineffective: See actual hazards. Ineffective: Worker set hammer down.
    5. 5. © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu The Lucky Barrier comes in here!!
    6. 6. © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Eight Questions For Insight Quality & Safety Impact What were the event consequences? What was the event significance? Vulnerability What set us up for the event? What triggered the event? What made the event as bad as it was? What kept it from being a lot worse? Learning: What should be learned from the event? Doing: What should be done about it? Consummation Exacerbation Mitigation Corrective Action (closeout) The Lucky Barrier comes in here!!
    7. 8. Lucky Barrier Case <ul><li>Submarine erroneously loads oxygen into potable water (PW) connection. PW vents inboard. (PW and O2 both color coded blue.) </li></ul><ul><li>Oxygen “enriches” submarine atmosphere. </li></ul><ul><li>If continued could lead to widespread fire. </li></ul><ul><li>Sailor inspecting trunk into which potable water vents notices his cigarette burning too well. </li></ul><ul><li>Sailor alerts the rest of the watch and load is terminated. </li></ul>© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Lucky Barrier
    8. 9. Lucky Barrier Case <ul><li>Operator attending to Motor Control Center. </li></ul><ul><li>Operator needs to have Control Room start the equipment. </li></ul><ul><li>No radio signal in front of MCC. </li></ul><ul><li>Operator moves to where signal is better. </li></ul><ul><li>MCC explodes when CR starts equipment. </li></ul><ul><li>Major arc flash near MCC. </li></ul><ul><li>Moving averted injury/fatality. </li></ul>Lucky Barrier
    9. 10. Lucky Barrier Case © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
    10. 11. Lucky Barrier Case <ul><li>Wrong valve identified for work. </li></ul><ul><li>Grinder cut into pressurized hydrogen line. </li></ul><ul><li>Grinder sparks ignite “Bunsen burner.” </li></ul><ul><li>Fire averts filling building with hydrogen. </li></ul><ul><li>No flammable material in Line-of-Fire. </li></ul>© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Lucky Barrier
    11. 12. Lucky Barrier Case <ul><li>Hoist Falls from Monorail. </li></ul><ul><li>Normally occupied area. </li></ul><ul><li>Not occupied (lucky barrier). </li></ul><ul><li>No personnel harm. </li></ul><ul><li>Potential fatality averted. </li></ul>© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Lucky Barrier
    12. 13. Lucky Barrier Case <ul><li>Pressurized Water Reactor. </li></ul><ul><li>PORV sticks open. </li></ul><ul><li>Pressurizer level pegs. </li></ul><ul><li>Operators turn off safety injection. </li></ul><ul><li>Not enough decay heat to melt fuel. </li></ul><ul><li>Precursor to TMI-2 meltdown. </li></ul>© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Lucky Barrier
    13. 14. Lucky Barrier Case <ul><li>Electrical Equipment Room (EER) Flooding. </li></ul><ul><li>Operators do not know it. </li></ul><ul><li>Security Officer randomly enters EER. </li></ul><ul><li>Security Officer gets wet feet. </li></ul><ul><li>Security Officer notifies Control Room. </li></ul><ul><li>Source of flooding isolated. </li></ul><ul><li>Severe equipment damage averted. </li></ul>© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Lucky Barrier
    14. 15. Lucky Barrier Case <ul><li>Scaffold built in line-of-fire of MSIV operator stroke. </li></ul><ul><li>Routine test impacts scaffold w/o damaging valve operator. </li></ul><ul><li>No personnel on scaffold (potential fatality averted). </li></ul><ul><li>Interference not sufficient to degrade valve safety function (potential risk increase averted). </li></ul>© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Lucky Barrier
    15. 16. Lucky Barrier Case <ul><li>U. S. Airways Flight 1549 engines strike Canada Geese </li></ul><ul><li>Has certain altitude and speed </li></ul><ul><li>No airports available </li></ul><ul><li>Pilot is glider expert </li></ul><ul><li>Passes 300’ above GW Bridge </li></ul><ul><li>Ditches in calm Hudson River </li></ul><ul><li>Does not hit ship traffic </li></ul><ul><li>Vessels nearby remove passengers and crew </li></ul>© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu 5 Lucky Barriers
    16. 17. Other Lucky Barrier Cases <ul><li>Davis-Besse 2002 </li></ul><ul><ul><li>LB=Leakage at Oconee </li></ul></ul><ul><li>NWA 253 (“Undie Bomber”) </li></ul><ul><ul><li>LB= Bomb did not detonate </li></ul></ul>
    17. 18. Send your favorite Lucky Barrier case to [email_address]
    18. 19. Lucky Barrier Facts <ul><li>Lucky Barriers tend to be inconsistent and unreliable. </li></ul><ul><li>Without the Lucky Barriers near misses would be Real McCoys. </li></ul><ul><li>Some of the most important corrective actions emerge from probing Lucky Barriers. </li></ul><ul><li>Important missed opportunities to prevent future consequences come from ignoring Lucky Barriers. </li></ul>© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
    19. 20. Lucky Barrier Lessons to be Learned <ul><li>Be sure you understand the factors that resulted in the nature, the magnitude, the location, and the timing of the most important consequences. </li></ul><ul><li>OBTW: Consequences can be actual, expected, or potential. </li></ul><ul><li>For every actual consequence one of the factors was a mitigating factor. </li></ul><ul><li>For every potential consequence one of the factors was a preventive factor. </li></ul>© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
    20. 21. Lucky Barrier Lessons to be Learned <ul><li>The Lucky Barriers will be among the preventive factors and mitigating factors. </li></ul><ul><li>Assess what the robustness of each Lucky Barrier was. </li></ul><ul><li>Assess what the consequences would have been without the Lucky Barriers, individually and jointly. </li></ul><ul><li>A Lucky Barrier should be interpreted as a “shot across the bow.” </li></ul>© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
    21. 22. Lucky Barrier(LB) Action Items <ul><li>Discuss the LBs in your Executive Summary. </li></ul><ul><li>Put the LBs in your Comparative TimeLine©. </li></ul><ul><li>Describe the LBs in your Narrative. </li></ul><ul><li>Put the LBs in your Barrier Analysis Matrix. </li></ul><ul><li>Put the LBs in your Factor Tree. </li></ul><ul><li>Put the LBs in your Event and Causal Factor Chart. </li></ul><ul><li>Pursue the Extent of Condition of other LBs. </li></ul><ul><li>Have Corrective Actions that make LBs unnecessary. </li></ul><ul><li>Adopt LBs as a standard Line of Inquiry (like LOW, Flawed Barriers, Error Precursors, etc.) </li></ul>© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
    22. 23. Oh, by the way. <ul><li>If you can take a picture of your Lucky Barrier, do so. </li></ul><ul><li>Use it in your RCAR. </li></ul>The Sailor who noticed the high oxygen. © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
    23. 24. Send your favorite Lucky Barrier action items and pictures to [email_address]
    24. 25. Lucky Barriers Bottom Line <ul><li>Luck is not a robust barrier. </li></ul><ul><li>Luck is an information-rich barrier. </li></ul><ul><li>Eliminating the need for LBs is a “no brainer.” </li></ul>© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu is a
    25. 26. Subscribe to “The Firebird Forum” by sending an e-mail to: [email_address]

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